University:
University of Nottingham
Course:
B723 | Midwifery
Academic year:

2024
Views:

443

Pages:

2
Author:

Christy C.

Source-Oriented Documentation and Narrative Format The narrative form is traditional recording and lasts the longest and is a flexible recording system. Because a narrative note is formed by the original source of the documentation, it is often referred to as source-oriented documentation. The source or origin of the document can be anyone from the health worker responsible for providing the information. Each resource person provides the results of his observations, describing his unique activities and evaluations.This way of writing follows strictly the sequence of events/chronology. Usually institutional policies outline who records/reports what, how something will be recorded and where it should be recorded. There are institutions that stipulate that each type of health worker must record on a form that has been specifically designed for them, for example a doctor's note, a midwife's note or a physiotherapist's or a nutritionist's note. There are also institutions that have designed formats that can be used for all types oDue to the open nature of narrative notes (orientation to the data source) so they can be used in every clinical condition. The absence of a structure to follow allows Midwives / Midwives to document relevant observations and events chronologically. Advantages of narrative notes 1. Chronological recording makes it easier to sequentially interpret the events of the care/actions carried out. 2. Give the midwife the freedom to take notes according to the preferred style. 3. The format simplifies the process of recording problems, change events, interventions, patient reactions and outcomes. Weaknesses of narrative recording 1. Tends to be a collection of disjointed, overlapping and actually less meaningful pieces of data. 2. Sometimes it is difficult to find information without reading the entire note or most of it. 3. Perpetuate a system of "burying orders" where the patient's problems are recorded superficially rather than exploring them in depth. 4. It is necessary to review records from all sources to understand the patient's overall clinical picture. 5. Can waste a lot of time because the plain format requires careful consideration to determine what information to record for each patient. 6. Chronological sequence of events can complicate interpretation because pertinent information may not be recorded in the same place. 7. Following patient progress can take up a lot of time.